Hernia DOI 10.1007/s10029-014-1319-4
ORIGINAL ARTICLE
Do we really know the symptoms of inguinal hernia? F. J. Pe´rez Lara • A. del Rey Moreno H. Oliva Mun˜oz
•
Received: 6 June 2014 / Accepted: 24 October 2014 Ó Springer-Verlag France 2014
Abstract Purpose Although there is a high incidence of inguinal hernia in developed countries, few studies have been conducted to describe the symptoms, and these few only address the local symptoms, not those presenting at other levels. The aim of the present study is to conduct a detailed review of the symptoms, both inguinal and otherwise, of patients with inguinal hernia. Methods A case–control study was designed to compare the symptoms presented by 231 patients diagnosed with inguinal hernia with those of a second group of 231 randomly-selected subjects. In the hernia group, the symptoms were also evaluated according to the location of the hernia (right, left, bilateral). Results Significant differences (more symptomatology in patients with hernia) were found for the following items: groin pain, genital pain, urinary symptoms, abdominal pain, increased peristalsis and tenesmus. On the contrary, the control patients presented greater symptomatology with respect to back pain and diaphragm pain. Conclusions Patients with inguinal hernia present a wide variety of symptoms, and these are not restricted to the inguinal area. It is important to be aware of this fact to convey accurate information to the patient, especially with regard to postoperative expectations.
F. J. Pe´rez Lara (&) Service of Surgery, Hospital de Antequera. Secretarı´a de Cirugı´a (3° planta), Avenida Poeta Mun˜oz Rojas s/n, Ma´laga, Antequera 29200, Spain e-mail: [email protected] A. del Rey Moreno H. Oliva Mun˜oz Hospital de Antequera, Ma´laga, Spain
Keywords Inguinal hernia Symptoms Additional tests Extraintestinal Abdominal pain Urinary symptoms
Introduction Inguinal hernia is a common cause of pain in the groin, and the third most important cause of patients’ requiring hospital emergency services due to a gastrointestinal pathology [1]. Most hernias are detectable on clinical examination. Clinical presentations range from the appearance of a bulge in the groin area, apparent on routine physical examination, to life-threatening presentations due to strangulation of the intestine. The general course of action is to repair the hernia, taking into account the patient’s clinical history and the findings of the clinical examination. However, a significant proportion of patients with symptoms suggestive of inguinal hernia presents normal results according to the clinical examination [2], as the hernia may be a small one, not clinically palpable. In such cases, imaging tests should be conducted to confirm or refute the diagnosis [3]. This can avoid unnecessary risks associated with surgical intervention in the groin, but for these imaging tests to be requested, there must be clinical suspicion of an inguinal hernia, and therefore it is very important to be well acquainted with the symptoms of these patients. However, in general, there exists very little information on the natural history and non-localised symptoms of inguinal hernias. Some studies have discussed the urinary symptoms of inguinal hernias [4], but we have been unable to locate any that describe extrainguinal symptoms or which quantify these symptoms. Therefore, in this paper we describe, quantify and compare with a control population all the symptoms presented by patients with inguinal hernia. In
123
Hernia
addition, we assess the diagnostic tests performed and the time elapsed until the patient attended the clinic to schedule surgical treatment.
Table 1 Symptoms questionnaire for patients with hernia (the same questionnaire was completed by the members of the control group, except the last two questions) Name Surname
Materials and methods A cross-sectional case–control study was conducted from March 2011 to February 2013. The case group consisted of 231 patients diagnosed at our clinic with inguinal hernia, during the study period. The control group consisted of 231 randomly-selected individuals. The two groups were similar in terms of sex and age. All potential subjects were informed of the possibility of entering the study, and those who consented were given a clinical questionnaire to complete, which specifically asked about certain symptoms (Table 1). The members of the case group were also asked about additional tests performed for their hernia diagnosis and about the time elapsed from when the hernia appeared until examination by the surgeon. The variables examined are qualitative in nature, and so the results are presented in terms of frequencies and percentages for each of the groups (case/control). Fisher’s test was applied to determine whether there existed any kind of association between the type of symptoms and the case/ control status. We also studied the case–control prevalence ratio (i.e., how many times the prevalence is greater among exposed compared to non-exposed subjects). A level of confidence of 95 % was applied, and the results were considered statistically significant if a critical value (p value) of less than 0.05 was obtained. The statistical analysis was performed by the FIMABIS AMEC Unit, Ma´laga (Spain) with software R project version 3.0.3.
Location of the hernia Do you feel pain in the area near the hernia? Do you feel pain in the groin area? Do you feel pain in your genitals? Do you have back pain? Do you have leg cramps? Do you feel discomfort when urinating or do you need to urinate more than normal? Do you feel pain in the diaphragm area? Do you feel abdominal pain? If you feel abdominal pain, in what area or areas? (please mark on the sketch)
Do you feel gas pains or have increased bowel movements? Do you sometimes feel the intense need to defecate? Are your bowel habits altered (diarrhoea/constipation) Have you lost weight recently? Have you had any tests because of the discomfort you have been experiencing? If so, please state which test or tests you have had? How long has it been since your hernia problems began?
Results
Briefly comment on any other symptoms experienced
The study was completed by 231 patients with hernia. 111 had right inguinal hernia (RIH), 89 had left inguinal hernia (LIH) and 31 had bilateral inguinal hernia (BIH). 196 were male (M) (87.01 %) and 35 were female (F) (12.99 %), with a mean age of 57.78 years (21–92); the standard deviation was 14.28. The distribution according to the location of the hernia was similar by sex (RIH M-84.68 %, F-15.32 %; LIH M-87.64 %, F-12.36 %; and BIH M-93.55 %, F-6.45 %) and age [RIH 56.36 (36–81), LIH 58.02 (21–84) and BIH 62.19 (24–92)]. In the case group, the following main symptoms were observed: pain in the hernia (69.26 %), groin pain (66.23 %) and increased peristalsis (49.78 %). Only
7.36 % of patients were asymptomatic (BIH 9.67 % RIH 6.3 % and LIH 7.87 %). The location of the abdominal pain (Fig. 1) was mainly in the lower abdomen, in sectors 7, 8 and 9, being most frequent in zone 9 in LIH and in zone 7 in RIH and BIH. The mean time elapsed from when the patients became aware of a hernia until they attended the clinic to schedule surgery was 244 days (20–1,825 days). Additional diagnostic tests were performed on 14.72 % of the patients (BIH 9.68 %, RIH 18.02 % and LIH 12.36 %). The most frequently used tests were abdominal ultrasound imaging (5.19 %) and abdominal radiography
123
Hernia Fig. 1 Distribution of abdominal pain by areas, according to the location of the hernia
25
RIH LIH 20
BIH Total Case
15
10
5
0 1
Fig. 2 Distribution of symptoms, according to the location of the hernia and in comparison with the control group
2
3
4
5
6
7
8
9
80
RIH
LIH
BIH
Total Case
Control
70 60 50 40 30 20 10 0 Abdominal Increased Tenesmus Altered bowel Groin pain Genital pain Back pain Cramping in Urinary Pain in peristalsis habits lower limbs symptoms diaphragmac pain area
(4.32 %), followed by inguinal ultrasound (1.30 %), abdominal CT (1.30 %), magnetic resonance (0.87 %), colonoscopy (0.87 %), oral endoscopy (0.43 %) and opaque enema (0.43 %). The control group was composed of 231 patients with a mean age of 60.02 years (21–86), SD 13.93. When the cases were compared with the controls (Fig. 2; Tables 2, 3, 4, 5), significant differences were apparent (greater symptomatology in patients with hernia) in the following variables: groin pain, genital pain, urinary symptoms, abdominal pain, increased peristalsis and tenesmus. The differences in the latter variable were significant for the patients with LIH, and those for the urinary symptoms variable were significant for patients with RIH; the remaining significant differences corresponded to both RIH and LIH. Finally, significant differences were found, with more symptoms observed in the control patients, for the variables back pain and diaphragm pain.
Weight Asymptomac loss
The prevalence ratios of cases (IH, RIH, LIH and BIH) to controls are shown in Table 6. Comparison of patients with RIH vs LIH (Table 7) revealed the presence of more symptoms in the first group, but the difference was not statistically significant.
Discussion The insurance industry and the judicial sector are increasingly interested in the aetiology, symptoms, diagnosis and postoperative complications of inguinal hernia, in relation to the acceptance of medical claims and to lost work time [5]. Not enough is known about inguinal hernia, and in consequence the rates of recovery reported vary widely from region to region and from country to country, from 10 per 10,000 in the UK to 28 per 10,000 in the United States [6]. One factor that can contribute to such differences is the
123
Hernia Table 2 Symptoms: status ratio (case/control)
Item
Groin pain
Levels
Case (n)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
153
66.5
66.5
16
7.0
7.0
169
36.7
36.7
No
77
33.5
100.0
214
93.0
100.0
291
63.3
100.0
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Genital pain
Yes
74
32.2
32.2
16
7.0
7.0
90
19.6
19.6
No
156
67.8
100.0
214
93.0
100.0
370
80.4
100.0
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Back pain
Yes No
58 172
25.2 74.8
106 124
46.1 53.9
164 296
35.6 64.3
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Cramping in lower limbs
Yes
53
23.0
23.0
39
17.0
17.0
92
20.0
20.0
No
177
77.0
100.0
191
83.0
100.0
368
80.0
100.0
p = 0.13
All
230
100.0
230
100.0
460
100.0
Urinary symptoms
Yes
70
30.4
30.4
44
19.1
19.1
114
24.8
24.8
No
160
69.6
100.0
186
80.9
100.0
346
75.2
100.0
p = 0.0068
All
230
100.0
230
100.0
460
100.0
Pain in diaphragmatic area
Yes
31
13.5
13.5
85
37.0
37.0
116
25.2
25.2
No
199
86.5
100.0
145
63.0
100.0
344
74.8
100.0
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Abdominal pain
Yes
70
30.4
30.4
35
15.2
15.2
105
22.8
22.8
No
160
69.6
100.0
195
84.8
100.0
355
77.2
100.0
p = 0.00014
All
230
100.0
230
100.0
460
100.0
Increased peristalsis
Yes
115
50.0
50.0
37
16.1
16.1
152
33.0
33.0
No
115
50.0
100.0
193
83.9
100.0
308
67.0
100.0
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Tenesmus
Yes
56
24.4
24.4
27
11.7
11.7
83
18.0
18.0
No
174
75.7
100.0
203
88.3
100.0
377
82.0
100.0
p = 0.00063
All
230
100.0
230
100.0
460
100.0
Altered bowel habits
Yes
40
17.4
17.4
44
19.1
19.1
84
18.3
18.3
No
190
82.6
100.0
186
80.9
100.0
376
81.7
100.0
p = 0.72 Weight loss
All Yes
230 29
100.0 12.6
12.6
230 23
100.0 10.0
10.0
460 52
100.0 11.3
11.3
No
201
87.4
100.0
207
90.0
100.0
408
88.7
100.0
All
230
100.0
230
100.0
460
100.0
p = 0.46 Bold values are statistically significant
Asymptomatic
Cases are defined as patients with IH
p = 0.00029
25.2 100.0
46.1 100.0
35.6 100.0
Yes
17
7.4
7.4
44
19.1
19.1
61
13.3
13.3
No
213
92.6
100.0
186
80.9
100.0
399
86.7
100.0
All
230
100.0
230
100.0
460
100.0
fact that patients not presenting local symptoms may not be aware that they have a hernia or may refuse to seek medical advice [7]. In the nineteenth century, it was thought that the cause of the hernia was a mechanical disparity between the visceral pressure and the strength of the abdominal muscles, due to deficiency in an abdominal wall, which was considered to be affected by weakness or ageing. Today, we have progressed from this simple concept to accept that it reflects a complex situation requiring combined input from
123
Case (%)
various fundamental areas of science to explain the numerous factors involved in its pathophysiology [8]. In the present study, the most common pain symptoms recorded were in the groin area, followed by genital pain and abdominal pain, especially in the hypogastrium and the iliac fossae. A common symptom associated with hernia is a discomfort or heaviness in the groin, which may or may not be associated with a visible bulge. Pain on standing or straining may be provoked by stretching the ilioinguinal nerve. This pain is often described as a ‘‘twinge’’ irradiated
Hernia Table 3 Symptoms: status ratio (case/control)
Item
Groin pain
Levels
Case (n)
Case (%)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
78
70.3
70.3
16
7.0
7.0
94
27.6
27.6
No
33
29.7
100.0
214
93.0
100.0
247
72.4
100.0
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Genital pain
Yes
33
29.7
29.7
16
7.0
7.0
49
14.4
14.4
No
78
70.3
100.0
214
93.0
100.0
292
85.6
100.0
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Back pain
Yes No
24 87
21.6 78.4
106 124
46.1 53.9
130 211
38.1 61.9
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Cramping in lower limbs
Yes
25
22.5
22.5
39
17.0
17.0
64
18.8
18.8
No
86
77.5
100.0
191
83.0
100.0
277
81.2
100.0
p = 0.24
All
111
100.0
230
100.0
341
100.0
Urinary symptoms
Yes
37
33.3
33.3
44
19.1
19.1
81
23.8
23.8
No
74
66.7
100.0
186
80.9
100.0
260
76.2
100.0
p = 0.0063
All
111
100.0
230
100.0
341
100.0
Pain in diaphragmatic area
Yes
11
9.9
9.9
85
37.0
37.0
96
28.1
28.1
No
100
90.1
100.0
145
63.0
100.0
245
71.8
100.0
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Abdominal pain
Yes
29
26.1
26.1
35
15.2
15.2
64
18.8
18.8
No
82
73.9
100.0
195
84.8
100.0
277
81.2
100.0
p = 0.02
All
111
100.0
230
100.0
341
100.0
Increased peristalsis
Yes
50
45.0
45.0
37
16.1
16.1
87
25.5
25.5
No
61
55.0
100.0
193
83.9
100.0
254
74.5
100.0
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Tenesmus
Yes
21
18.9
18.9
27
11.7
11.7
48
14.1
14.1
No
90
81.1
100.0
203
88.3
100.0
293
85.9
100.0
p = 0.10
All
111
100.0
230
100.0
341
100.0
Altered bowel habits
Yes
17
15.3
15.3
44
19.1
19.1
61
17.9
17.9
No
94
84.7
100.0
186
80.9
100.0
280
82.1
100.0
p = 0.45 Weight loss
All Yes
111 12
100.0 10.8
10.8
230 23
100.0 10.0
10.0
341 35
100.0 10.3
10.3
No
99
89.2
100.0
207
90.0
100.0
306
89.7
100.0
All
111
100.0
230
100.0
341
100.0
p = 0.85 Bold values are statistically significant
Asymptomatic
Cases are defined as patients with IH
p = 0.0018
Yes
21.6 100.0
46.1 100.0
38.1 100.0
7
6.3
6.3
44
19.1
19.1
51
15.0
15.0
No
104
93.7
100.0
186
80.9
100.0
290
85.0
100.0
All
111
100.0
230
100.0
341
100.0
when the nerve is stretched, which rapidly disappears on release. It takes very little pressure to create discomfort, which resolves when the patient stops straining or sits down [9]. Moderate-severe pain due to hernia is rare, and when present, should suggest the possibility of incarceration or strangulation, which becomes more likely the longer the hernia has been present [10]. In the present study, 30.4 % of the patients with hernia presented urological symptoms, and this figure rose to 33.3 % in cases of RIH. Inguinal hernia is known to be
associated with urological symptoms, and several factors have been described as being involved [8]. On the one hand, the target organ of all the harmful stimuli known in the hernia is the collagen matrix, which is also related to the ageing process in the bladder and other organs. Another possible explanation for this association is that patients with obstructive voiding dysfunction may need to make an effort to urinate, and over time this effort can have a direct impact on the abdominal wall, thus contributing to the development of inguinal hernia. A third
123
Hernia Table 4 Symptoms: status ratio (case/control)
Item
Groin pain
Case (n)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
54
60.7
60.7
16
7.0
7.0
70
21.9
21.9
35
39.3
100.0
214
93.0
100.0
249
78.1
100.0
p < 0.0001
All
89
100.0
230
100.0
319
100.0
Genital pain
Yes
29
32.6
32.6
16
7.0
7.0
45
14.1
14.1
No
60
67.4
100.0
214
93.0
100.0
274
85.9
100.0
p < 0.0001
All
89
100.0
230
100.0
319
100.0
Back pain
Yes No
29 60
32.6 67.4
106 124
46.1 53.9
135 184
42.3 57.7
p = 0.03
All
89
100.0
230
100.0
319
100.0
Cramping in lower limbs
Yes
20
22.5
22.5
39
17.0
17.0
59
18.5
18.5
No
69
77.5
100.0
191
83.0
100.0
260
81.5
100.0
32.6 100.0
46.1 100.0
42.3 100.0
p = 0.26
All
89
100.0
230
100.0
319
100.0
Urinary symptoms
Yes
24
27.0
27.0
44
19.1
19.1
68
21.3
21.3
No
65
73.0
100.0
186
80.9
100.0
251
78.7
100.0
p = 0.13
All
89
100.0
230
100.0
319
100.0
Pain in diaphragmatic area
Yes
17
19.1
19.1
85
37.0
37.0
102
32.0
32.0
No
72
80.9
100.0
145
63.0
100.0
217
68.0
100.0
p = 0.0021
All
89
100.0
230
100.0
319
100.0
Abdominal pain
Yes
33
37.1
37.1
35
15.2
15.2
68
21.3
21.3
No
56
62.9
100.0
195
84.8
100.0
251
78.7
100.0
p < 0.0001
All
89
100.0
230
100.0
319
100.0
Increased peristalsis
Yes
48
53.9
53.9
37
16.1
16.1
85
26.6
26.6
No
41
46.1
100.0
193
83.9
100.0
234
73.3
100.0
p < 0.0001
All
89
100.0
230
100.0
319
100.0
Tenesmus
Yes
23
25.8
25.8
27
11.7
11.7
50
15.7
15.7
No
66
74.2
100.0
203
88.3
100.0
269
84.3
100.0
230
100.0
319
100.0
44
19.1
19.1
59
18.5
18.5 100.0
p = 0.0032
All
89
100.0
Altered bowel habits
Yes
15
16.9
16.9
No
74
83.2
100.0
186
80.9
100.0
260
81.5
p = 0.75 Weight loss
All Yes
89 14
100.0 15.7
15.7
230 23
100.0 10.0
10.0
319 37
100.0 11.6
11.6
No
75
84.3
100.0
207
90.0
100.0
282
88.4
100.0
All
89
100.0
230
100.0
319
100.0
Asymptomatic p = 0.02
Yes
7
7.9
7.9
44
19.1
19.1
51
16.0
16.0
No
82
92.1
100.0
186
80.9
100.0
268
84.0
100.0
All
89
100.0
230
100.0
319
100.0
explanation is based on the fact that inguinal hernia and benign prostatic hypertrophy are part of the ageing process, which provokes functional and anatomical changes. Furthermore, up to 4 % of inguinal hernias may contain part of the bladder (ranging from a small proportion to over half of this organ), which may also provoke urological symptoms [11]. Whether these changes, as a whole, have a cause-effect relationship or are independent factors that are only related to the ageing process has yet to be defined [4].
123
Case (%)
No
p = 0.17
Bold values are statistically significant
Levels
However, except for these symptoms related to local mechanical pressure and urological symptoms, we have not found any previous studies that have considered in greater detail the symptoms presented by patients at other levels, as being related directly or indirectly with inguinal hernia. In this study, we observed more gastrointestinal symptoms in the cases than in the control population, possibly as a result of compression of structures in the digestive tract. For the same reason, hernia patients more commonly present with chronic abdominal pain. One detail that should
Hernia Table 5 Symptoms: status ratio (case/control). Cases are defined as patients with BIH
Item
Groin pain
Case (n)
Case (%)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
21
70.0
70.0
16
7.0
7.0
37
14.2
14.2
No
9
30.0
100.0
214
93.0
100.0
223
85.8
100.0
p < 0.0001
All
30
100.0
230
100.0
260
100.0
Genital pain
Yes
12
40.0
40.0
16
7.0
7.0
28
10.8
10.8
No
18
60.0
100.0
214
93.0
100.0
232
89.2
100.0
p < 0.0001
All
30
100.0
230
100.0
260
100.0
Back pain
Yes No
5 25
16.7 83.3
106 124
46.1 53.9
111 149
42.7 57.3
p = 0.0027
All
30
100.0
230
100.0
260
100.0
Cramping in lower limbs
Yes
8
26.7
26.7
39
17.0
17.0
47
18.1
18.1
No
22
73.3
100.0
191
83.0
100.0
213
81.9
100.0
16.7 100.0
46.1 100.0
42.7 100.0
p = 0.21
All
30
100.0
230
100.0
260
100.0
Urinary symptoms
Yes
9
30.0
30.0
44
19.1
19.1
53
20.4
20.4
No
21
70.0
100.0
186
80.9
100.0
207
79.6
100.0
p = 0.23
All
30
100.0
230
100.0
260
100.0
Pain in diaphragmatic area
Yes
3
10.0
10.0
85
37.0
37.0
88
33.9
33.9
No
27
90.0
100.0
145
63.0
100.0
172
66.2
100.0
p = 0.0034
All
30
100.0
230
100.0
260
100.0
Abdominal pain
Yes
8
26.7
26.7
35
15.2
15.2
43
16.5
16.5
No
22
73.3
100.0
195
84.8
100.0
217
83.5
100.0
p = 0.12
All
30
100.0
230
100.0
260
100.0
Increased peristalsis
Yes
17
56.7
56.7
37
16.1
16.1
54
20.8
20.8
No
13
43.3
100.0
193
83.9
100.0
206
79.2
100.0
p < 0.0001
All
30
100.0
230
100.0
260
100.0
Tenesmus
Yes
12
40.0
40.0
27
11.7
11.7
39
15.0
15.0
No
18
60.0
100.0
203
88.3
100.0
221
85.0
100.0
230
100.0
260
100.0
44
19.1
19.1
52
20.0
20.0 100.0
p = 0.00031
All
30
100.0
Altered bowel habits
Yes
8
26.7
26.7
No
22
73.3
100.0
186
80.9
100.0
208
80.0
p = 0.34 Weight loss
All Yes
30 3
100.0 10.0
10.0
230 23
100.0 10.0
10.0
260 26
100.0 10.0
10.0
No
27
90.0
100.0
207
90.0
100.0
234
90.0
100.0
All
30
100.0
230
100.0
260
100.0
p = 1.00 Asymptomatic Bold values are statistically significant
Levels
p = 0.31
Yes
3
10.0
10.0
44
19.1
19.1
47
18.1
18.1
No
27
90.0
100.0
186
80.9
100.0
213
81.9
100.0
All
30
100.0
230
100.0
260
100.0
be taken into account (although in this respect, the differences in this study were not statistically significant) is that gastrointestinal symptoms and abdominal pain are both more commonly present in LIH than in RIH, probably because the sigma is a structure that passes easily through the left hernial orifice. Another point that arose in our study is that, curiously, there was a lower incidence of back pain and diaphragm pain among the hernia patients than in the control group.
This finding may be related to the existence of a gating mechanism on the medullary dorsal horn [12]. When a painful stimulus on the skin occurs, two types of fibres are activated: on the one hand, fine fibres, which are unmyelinated or poorly myelinated, which produce the painful stimulus; and on the other hand, thick, myelinated fibres, which produce proprioceptive stimuli, carried by afferent pathways to the medullary dorsal horn, where they exert an inhibitory modulation of the pain [13].
123
123
1.7588 1.2150 1.4618 2.7040 1.2999 1.8748 2.0496 0.9898 1.4243 7.2095 3.7778 Tenesmus
1.9796
0.6327
1.7663 2.4030 1.2387 1.7087
0.3373 0.4620
1.4792 2.0263 3.0452 4.5048
0.8063 0.3129
1.5537 2.3059 2.1752 3.2230
0.5023 0.4995
2.1178 3.1783 1.1063 1.8018
0.1578 0.2807
1.5307 2.3931 3.8466 9.6232
0.6961 0.0678
Abdominal pain Increased bowel movements
0.8755 2.5861
0.2172
1.8351 4.9886
Phrenic pain
1.4701
1.5971 1.1040
0.9758 1.1977
1.3279 2.0007
1.9241 0.8479
0.9284 1.3629
1.2773 1.7904
2.1791 1.1821
0.8842 1.2582
1.6049 3.4396
3.4714 0.7823
Urinary symptoms
0.8146
1.6480
1.6739
‘Twinging’ leg
0.7648 0.4843 0.6086 0.9668 0.4489 0.6588 0.6650 0.3015 0.4477 0.6792 0.2685 Back pain
0.1061
2.2730
4.1691 2.8078
1.6731 1.9501
3.4214 7.6533
4.0190 2.1550
3.9355 5.4882
2.9430 3.3100
8.6435 4.4628
1.9204 2.5212
6.2108 28.2933
10.2301 5.5238 Genital pain
6.9900 14.0631 Inguinal pain
2.9826
Lower.CI PR Lower.CI PR Lower.CI PR PR Item
Lower.CI
Upper.CI
Right inguinal hernia Bilateral inguinal hernia
Table 6 Prevalence ratio for the case groups (BIH, RIH, LIH, IH) vs controls
Upper.CI
Left inguinal hernia
Upper.CI
Inguinal hernia
Upper.CI
Hernia
This theory is the basis for the transcutaneous electrical nerve stimulation applied in pain management. In the present case, therefore, the chronic activation of these same afferent pathways in patients with inguinal hernia would exert inhibitory modulation at the level of the spinal dorsal horn, which would explain the lower frequency or intensity of pain [14]. Despite the existence of all the above-mentioned symptoms, some studies have shown that among a significant proportion of patients with symptoms suggestive of inguinal hernia, clinical examination fails to reveal any such hernia [2]. In these cases, imaging tests must be used for diagnosis. In our case group, additional tests were requested for 11.68 % of the patients, with inguinal ultrasound being the most requested (5.19 %). This latter finding is logical, because this test has a sensitivity of 86 % and a specificity of 77 % with respect to hidden inguinal hernias [3]. Hair et al. [15] showed that up to a third of patients presenting with inguinal hernia are asymptomatic at presentation, and that of those suffering pain, this has little effect on their leisure or work activities. However, in our own study only 7.4 % of patients reported being asymptomatic. This difference might have arisen because we took into account a greater number of symptoms, not just locally but also at other levels. Thus, we found a number of physical symptoms and pain-related symptoms occurring at a frequency higher than that observed in the control group. This coincides with other studies [16, 17] in which the SF-36 [18] questionnaire has been used to assess the impact of inguinal hernia on quality of life, and which have concluded that physical functioning, bodily pain and physical role were the domains most affected among patients before hernia repair. In the present study, however, we examine, in particular, the physical functions that are affected (urinary symptoms, increased peristalsis and tenesmus) and the areas most affected by pain (genital, inguinal and abdominal). In view of the above considerations, we believe that the symptoms of patients with inguinal hernia are determined by the constriction of the contents of the hernia within the neck of the sac, and so depending on the content, the symptoms may range from urinary symptoms (entrapment of the bladder neck) to gastrointestinal symptoms (entrapment of the small or large intestine) or the pain symptoms described above (nerve compression). Accordingly, we consider it important to be aware of the symptoms that may develop as a consequence of inguinal hernia, to be able to convey more accurate information to patients when scheduling surgery for inguinal hernia, especially in terms of expectations of symptoms that could be alleviated by the intervention.
Hernia Table 7 Symptoms: status ratio (RIH/LIH)
Item
Groin pain
Levels
Case (n)
Case (%)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
78
70.3
70.3
54
60.7
60.7
132
66.0
66.0
No
33
29.7
100.0
35
39.3
100.0
68
34.0
100.0
p = 0.18
All
111
100.0
89
100.0
200
100.0
Genital pain
Yes
33
29.7
29.7
29
32.6
32.6
62
31.0
31.0
No
78
70.3
100.0
60
67.4
100.0
138
69.0
100.0
p = 0.76
All
111
100.0
89
100.0
200
100.0
Back pain
Yes No
24 87
21.6 78.4
29 60
32.6 67.4
53 147
26.5 73.5
p = 0.11
All
111
100.0
89
100.0
200
100.0
Cramping in lower limbs
Yes
25
22.5
22.5
20
22.5
22.5
45
22.5
22.5
No
86
77.5
100.0
69
77.5
100.0
155
77.5
100.0
p = 1.00
All
111
100.0
89
100.0
200
100.0
Urinary symptoms
Yes
37
33.3
33.3
24
27.0
27.0
61
30.5
30.5
No
74
66.7
100.0
65
73.0
100.0
139
69.5
100.0
p = 0.36
All
111
100.0
89
100.0
200
100.0
Pain in diaphragmatic area
Yes
11
9.9
9.9
17
19.1
19.1
28
14.0
14.0
No
100
90.1
100.0
72
80.9
100.0
172
86.0
100.0
p = 0.07
All
111
100.0
89
100.0
200
100.0
Abdominal pain
Yes
29
26.1
26.1
33
37.1
37.1
62
31.0
31.0
No
82
73.9
100.0
56
62.9
100.0
138
69.0
100.0
p = 0.12
All
111
100.0
89
100.0
200
100.0
Increased peristalsis
Yes
50
45.0
45.0
48
53.9
53.9
98
49.0
49.0
No
61
55.0
100.0
100.0
100.0
p = 0.26
All
111
100.0
Tenesmus
Yes
21
18.9
No
90
81.1
p = 0.30
All
111
100.0
Altered bowel habits
Yes
17
15.3
15.3
No
94
84.7
100.0
p = 0.85 Weight loss
All Yes
111 12
100.0 10.8
No
99
89.2
All
111
100.0
p = 0.40 Asymptomatic p = 0.78
Yes
21.6 100.0
32.6 100.0
41
46.1
89
100.0
18.9
23
25.8
100.0
66
74.2
89
100.0
15
16.9
16.9
74
83.2
100.0
10.8
89 14
100.0 15.7
100.0
75
84.3
89
100.0
26.5 100.0
102
51.0
200
100.0
25.8
44
22.0
22.0
100.0
156
78.0
100.0
200
100.0
32
16.0
16.0
168
84.0
100.0
15.7
200 26
100.0 13.0
13.0
100.0
174
87.0
100.0
200
100.0
7
6.3
6.3
7
7.9
7.9
14
7.0
7.0
No
104
93.7
100.0
82
92.1
100.0
186
93.0
100.0
All
111
100.0
89
100.0
200
100.0
Acknowledgments We are grateful to Rita Perez (FIMABIS) for support on the statistical analysis. Conflict of interest FJPL declares no conflict of interest. ARM declares no conflict of interest. HOM declares no conflict of interest. Author contribution FJ. Pe´rez Lara: Conception and design, acquisition of data, analysis and interpretation of data, drafting the article, final approval of the version to be published. A. del Rey Moreno: Acquisition of data, revising the article critically for important intellectual content, final approval of the version to be published. H. Oliva Mun˜oz: Acquisition of data, revising the article
critically for important intellectual content, final approval of the version to be published.
References 1. Everhart JE (2008) The burden of digestive diseases in the United States. NIH Publication No. 09-6443, US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. US Government Printing Office, Washington, DC
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Hernia 2. Kark A, Kurzer M, Waters KJ (1994) Accuracy of clinical diagnosis of direct and indirect inguinal hernia. Br J Surg 81:1081–1082 3. Robisnson A, Light D, Kasim A, Nice C (2013) A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc 27:11–18 4. dos Reis RB, Rodrigues Neto AA, Oliveira Reis L, Dias Machado R, Kaplan S (2011) Correlation between the presence of inguinal hernia and the intensity of lower urinary tract symptoms. Acta Ciru´rgica Brasileira 26(2):125–128 5. O’Rourke MGE, O’Rourke TR (2012) Inguinal hernia: aetiology, diagnosis, postrepair pain and compensation. ANZ J Surg 82:201–206 6. Ham C (ed) (1988) Research reports: health care variations. Assessing the evidence. Kings Fund Institute, London 7. McEntee GP, Carroll AO, Mooney B et al (1989) Timing of strangulation in adult hernias. Br J Surg 76:725–726 8. Bendavid R (2004) The unified theory of hernia formation. Hernia 8:171–176 9. Tanaka N, Uchida N, Ogihara H, Sasamoto H, Kato H, Kuwano H (2010) Clinical study of inguinal and femoral incarcerated hernias. Surg Today 40(12):1144–1147
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10. Gallegos NC, Dawson J, Jarvis M, Hobsley M (1991) Risk of strangulation in groin hernias. Br J Surg 78:1171–1173 11. Westera J, Meyer J, Reynolds J, Lambrianides AL (2012) Massive inguinoscrotal bladder hernia. J Surg Case Rep 5:5 12. Melzack R, Wall PD (1967) Pain mechanisms: a new theory. Surv Anesthesiol 11(2):89–90 13. Dickenson AH, Editorial I (2002) Gate control theory of pain stands the test of time. Br J Anaesth 88(6):755–757 14. Dickenson AH (2008) The neurobiology of chronic pain states. Anaesth Intensive Care Med 9(1):8–12 15. Hair A, Paterson C, Wright D, Baxter JN, O’Dwyer PJ (2001) What effect does the duration of an inguinal hernia have on patient symptoms? J Am Coll Surg 193(2):125–129 16. Sullivan M, Karlsson J (1998) The Swedish SF-36 health survey III. Evaluation of criterion-based validity: results from normative population. J Clin Epidemiol 51:1105–1113 17. Bitzer EM, Lorentz C, Nickel S, Do¨rning H, Trojan A (2008) Patient-reported outcomes in hernia repair. Hernia 12:407–414 18. Mathur S, Bartlett AS, Gilkison W, Krishna G (2006) Quality of life assessment in patients with inguinal hernia. ANZ J Surg 76:491–493
ORIGINAL ARTICLE
Do we really know the symptoms of inguinal hernia? F. J. Pe´rez Lara • A. del Rey Moreno H. Oliva Mun˜oz
•
Received: 6 June 2014 / Accepted: 24 October 2014 Ó Springer-Verlag France 2014
Abstract Purpose Although there is a high incidence of inguinal hernia in developed countries, few studies have been conducted to describe the symptoms, and these few only address the local symptoms, not those presenting at other levels. The aim of the present study is to conduct a detailed review of the symptoms, both inguinal and otherwise, of patients with inguinal hernia. Methods A case–control study was designed to compare the symptoms presented by 231 patients diagnosed with inguinal hernia with those of a second group of 231 randomly-selected subjects. In the hernia group, the symptoms were also evaluated according to the location of the hernia (right, left, bilateral). Results Significant differences (more symptomatology in patients with hernia) were found for the following items: groin pain, genital pain, urinary symptoms, abdominal pain, increased peristalsis and tenesmus. On the contrary, the control patients presented greater symptomatology with respect to back pain and diaphragm pain. Conclusions Patients with inguinal hernia present a wide variety of symptoms, and these are not restricted to the inguinal area. It is important to be aware of this fact to convey accurate information to the patient, especially with regard to postoperative expectations.
F. J. Pe´rez Lara (&) Service of Surgery, Hospital de Antequera. Secretarı´a de Cirugı´a (3° planta), Avenida Poeta Mun˜oz Rojas s/n, Ma´laga, Antequera 29200, Spain e-mail: [email protected] A. del Rey Moreno H. Oliva Mun˜oz Hospital de Antequera, Ma´laga, Spain
Keywords Inguinal hernia Symptoms Additional tests Extraintestinal Abdominal pain Urinary symptoms
Introduction Inguinal hernia is a common cause of pain in the groin, and the third most important cause of patients’ requiring hospital emergency services due to a gastrointestinal pathology [1]. Most hernias are detectable on clinical examination. Clinical presentations range from the appearance of a bulge in the groin area, apparent on routine physical examination, to life-threatening presentations due to strangulation of the intestine. The general course of action is to repair the hernia, taking into account the patient’s clinical history and the findings of the clinical examination. However, a significant proportion of patients with symptoms suggestive of inguinal hernia presents normal results according to the clinical examination [2], as the hernia may be a small one, not clinically palpable. In such cases, imaging tests should be conducted to confirm or refute the diagnosis [3]. This can avoid unnecessary risks associated with surgical intervention in the groin, but for these imaging tests to be requested, there must be clinical suspicion of an inguinal hernia, and therefore it is very important to be well acquainted with the symptoms of these patients. However, in general, there exists very little information on the natural history and non-localised symptoms of inguinal hernias. Some studies have discussed the urinary symptoms of inguinal hernias [4], but we have been unable to locate any that describe extrainguinal symptoms or which quantify these symptoms. Therefore, in this paper we describe, quantify and compare with a control population all the symptoms presented by patients with inguinal hernia. In
123
Hernia
addition, we assess the diagnostic tests performed and the time elapsed until the patient attended the clinic to schedule surgical treatment.
Table 1 Symptoms questionnaire for patients with hernia (the same questionnaire was completed by the members of the control group, except the last two questions) Name Surname
Materials and methods A cross-sectional case–control study was conducted from March 2011 to February 2013. The case group consisted of 231 patients diagnosed at our clinic with inguinal hernia, during the study period. The control group consisted of 231 randomly-selected individuals. The two groups were similar in terms of sex and age. All potential subjects were informed of the possibility of entering the study, and those who consented were given a clinical questionnaire to complete, which specifically asked about certain symptoms (Table 1). The members of the case group were also asked about additional tests performed for their hernia diagnosis and about the time elapsed from when the hernia appeared until examination by the surgeon. The variables examined are qualitative in nature, and so the results are presented in terms of frequencies and percentages for each of the groups (case/control). Fisher’s test was applied to determine whether there existed any kind of association between the type of symptoms and the case/ control status. We also studied the case–control prevalence ratio (i.e., how many times the prevalence is greater among exposed compared to non-exposed subjects). A level of confidence of 95 % was applied, and the results were considered statistically significant if a critical value (p value) of less than 0.05 was obtained. The statistical analysis was performed by the FIMABIS AMEC Unit, Ma´laga (Spain) with software R project version 3.0.3.
Location of the hernia Do you feel pain in the area near the hernia? Do you feel pain in the groin area? Do you feel pain in your genitals? Do you have back pain? Do you have leg cramps? Do you feel discomfort when urinating or do you need to urinate more than normal? Do you feel pain in the diaphragm area? Do you feel abdominal pain? If you feel abdominal pain, in what area or areas? (please mark on the sketch)
Do you feel gas pains or have increased bowel movements? Do you sometimes feel the intense need to defecate? Are your bowel habits altered (diarrhoea/constipation) Have you lost weight recently? Have you had any tests because of the discomfort you have been experiencing? If so, please state which test or tests you have had? How long has it been since your hernia problems began?
Results
Briefly comment on any other symptoms experienced
The study was completed by 231 patients with hernia. 111 had right inguinal hernia (RIH), 89 had left inguinal hernia (LIH) and 31 had bilateral inguinal hernia (BIH). 196 were male (M) (87.01 %) and 35 were female (F) (12.99 %), with a mean age of 57.78 years (21–92); the standard deviation was 14.28. The distribution according to the location of the hernia was similar by sex (RIH M-84.68 %, F-15.32 %; LIH M-87.64 %, F-12.36 %; and BIH M-93.55 %, F-6.45 %) and age [RIH 56.36 (36–81), LIH 58.02 (21–84) and BIH 62.19 (24–92)]. In the case group, the following main symptoms were observed: pain in the hernia (69.26 %), groin pain (66.23 %) and increased peristalsis (49.78 %). Only
7.36 % of patients were asymptomatic (BIH 9.67 % RIH 6.3 % and LIH 7.87 %). The location of the abdominal pain (Fig. 1) was mainly in the lower abdomen, in sectors 7, 8 and 9, being most frequent in zone 9 in LIH and in zone 7 in RIH and BIH. The mean time elapsed from when the patients became aware of a hernia until they attended the clinic to schedule surgery was 244 days (20–1,825 days). Additional diagnostic tests were performed on 14.72 % of the patients (BIH 9.68 %, RIH 18.02 % and LIH 12.36 %). The most frequently used tests were abdominal ultrasound imaging (5.19 %) and abdominal radiography
123
Hernia Fig. 1 Distribution of abdominal pain by areas, according to the location of the hernia
25
RIH LIH 20
BIH Total Case
15
10
5
0 1
Fig. 2 Distribution of symptoms, according to the location of the hernia and in comparison with the control group
2
3
4
5
6
7
8
9
80
RIH
LIH
BIH
Total Case
Control
70 60 50 40 30 20 10 0 Abdominal Increased Tenesmus Altered bowel Groin pain Genital pain Back pain Cramping in Urinary Pain in peristalsis habits lower limbs symptoms diaphragmac pain area
(4.32 %), followed by inguinal ultrasound (1.30 %), abdominal CT (1.30 %), magnetic resonance (0.87 %), colonoscopy (0.87 %), oral endoscopy (0.43 %) and opaque enema (0.43 %). The control group was composed of 231 patients with a mean age of 60.02 years (21–86), SD 13.93. When the cases were compared with the controls (Fig. 2; Tables 2, 3, 4, 5), significant differences were apparent (greater symptomatology in patients with hernia) in the following variables: groin pain, genital pain, urinary symptoms, abdominal pain, increased peristalsis and tenesmus. The differences in the latter variable were significant for the patients with LIH, and those for the urinary symptoms variable were significant for patients with RIH; the remaining significant differences corresponded to both RIH and LIH. Finally, significant differences were found, with more symptoms observed in the control patients, for the variables back pain and diaphragm pain.
Weight Asymptomac loss
The prevalence ratios of cases (IH, RIH, LIH and BIH) to controls are shown in Table 6. Comparison of patients with RIH vs LIH (Table 7) revealed the presence of more symptoms in the first group, but the difference was not statistically significant.
Discussion The insurance industry and the judicial sector are increasingly interested in the aetiology, symptoms, diagnosis and postoperative complications of inguinal hernia, in relation to the acceptance of medical claims and to lost work time [5]. Not enough is known about inguinal hernia, and in consequence the rates of recovery reported vary widely from region to region and from country to country, from 10 per 10,000 in the UK to 28 per 10,000 in the United States [6]. One factor that can contribute to such differences is the
123
Hernia Table 2 Symptoms: status ratio (case/control)
Item
Groin pain
Levels
Case (n)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
153
66.5
66.5
16
7.0
7.0
169
36.7
36.7
No
77
33.5
100.0
214
93.0
100.0
291
63.3
100.0
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Genital pain
Yes
74
32.2
32.2
16
7.0
7.0
90
19.6
19.6
No
156
67.8
100.0
214
93.0
100.0
370
80.4
100.0
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Back pain
Yes No
58 172
25.2 74.8
106 124
46.1 53.9
164 296
35.6 64.3
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Cramping in lower limbs
Yes
53
23.0
23.0
39
17.0
17.0
92
20.0
20.0
No
177
77.0
100.0
191
83.0
100.0
368
80.0
100.0
p = 0.13
All
230
100.0
230
100.0
460
100.0
Urinary symptoms
Yes
70
30.4
30.4
44
19.1
19.1
114
24.8
24.8
No
160
69.6
100.0
186
80.9
100.0
346
75.2
100.0
p = 0.0068
All
230
100.0
230
100.0
460
100.0
Pain in diaphragmatic area
Yes
31
13.5
13.5
85
37.0
37.0
116
25.2
25.2
No
199
86.5
100.0
145
63.0
100.0
344
74.8
100.0
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Abdominal pain
Yes
70
30.4
30.4
35
15.2
15.2
105
22.8
22.8
No
160
69.6
100.0
195
84.8
100.0
355
77.2
100.0
p = 0.00014
All
230
100.0
230
100.0
460
100.0
Increased peristalsis
Yes
115
50.0
50.0
37
16.1
16.1
152
33.0
33.0
No
115
50.0
100.0
193
83.9
100.0
308
67.0
100.0
p < 0.0001
All
230
100.0
230
100.0
460
100.0
Tenesmus
Yes
56
24.4
24.4
27
11.7
11.7
83
18.0
18.0
No
174
75.7
100.0
203
88.3
100.0
377
82.0
100.0
p = 0.00063
All
230
100.0
230
100.0
460
100.0
Altered bowel habits
Yes
40
17.4
17.4
44
19.1
19.1
84
18.3
18.3
No
190
82.6
100.0
186
80.9
100.0
376
81.7
100.0
p = 0.72 Weight loss
All Yes
230 29
100.0 12.6
12.6
230 23
100.0 10.0
10.0
460 52
100.0 11.3
11.3
No
201
87.4
100.0
207
90.0
100.0
408
88.7
100.0
All
230
100.0
230
100.0
460
100.0
p = 0.46 Bold values are statistically significant
Asymptomatic
Cases are defined as patients with IH
p = 0.00029
25.2 100.0
46.1 100.0
35.6 100.0
Yes
17
7.4
7.4
44
19.1
19.1
61
13.3
13.3
No
213
92.6
100.0
186
80.9
100.0
399
86.7
100.0
All
230
100.0
230
100.0
460
100.0
fact that patients not presenting local symptoms may not be aware that they have a hernia or may refuse to seek medical advice [7]. In the nineteenth century, it was thought that the cause of the hernia was a mechanical disparity between the visceral pressure and the strength of the abdominal muscles, due to deficiency in an abdominal wall, which was considered to be affected by weakness or ageing. Today, we have progressed from this simple concept to accept that it reflects a complex situation requiring combined input from
123
Case (%)
various fundamental areas of science to explain the numerous factors involved in its pathophysiology [8]. In the present study, the most common pain symptoms recorded were in the groin area, followed by genital pain and abdominal pain, especially in the hypogastrium and the iliac fossae. A common symptom associated with hernia is a discomfort or heaviness in the groin, which may or may not be associated with a visible bulge. Pain on standing or straining may be provoked by stretching the ilioinguinal nerve. This pain is often described as a ‘‘twinge’’ irradiated
Hernia Table 3 Symptoms: status ratio (case/control)
Item
Groin pain
Levels
Case (n)
Case (%)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
78
70.3
70.3
16
7.0
7.0
94
27.6
27.6
No
33
29.7
100.0
214
93.0
100.0
247
72.4
100.0
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Genital pain
Yes
33
29.7
29.7
16
7.0
7.0
49
14.4
14.4
No
78
70.3
100.0
214
93.0
100.0
292
85.6
100.0
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Back pain
Yes No
24 87
21.6 78.4
106 124
46.1 53.9
130 211
38.1 61.9
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Cramping in lower limbs
Yes
25
22.5
22.5
39
17.0
17.0
64
18.8
18.8
No
86
77.5
100.0
191
83.0
100.0
277
81.2
100.0
p = 0.24
All
111
100.0
230
100.0
341
100.0
Urinary symptoms
Yes
37
33.3
33.3
44
19.1
19.1
81
23.8
23.8
No
74
66.7
100.0
186
80.9
100.0
260
76.2
100.0
p = 0.0063
All
111
100.0
230
100.0
341
100.0
Pain in diaphragmatic area
Yes
11
9.9
9.9
85
37.0
37.0
96
28.1
28.1
No
100
90.1
100.0
145
63.0
100.0
245
71.8
100.0
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Abdominal pain
Yes
29
26.1
26.1
35
15.2
15.2
64
18.8
18.8
No
82
73.9
100.0
195
84.8
100.0
277
81.2
100.0
p = 0.02
All
111
100.0
230
100.0
341
100.0
Increased peristalsis
Yes
50
45.0
45.0
37
16.1
16.1
87
25.5
25.5
No
61
55.0
100.0
193
83.9
100.0
254
74.5
100.0
p < 0.0001
All
111
100.0
230
100.0
341
100.0
Tenesmus
Yes
21
18.9
18.9
27
11.7
11.7
48
14.1
14.1
No
90
81.1
100.0
203
88.3
100.0
293
85.9
100.0
p = 0.10
All
111
100.0
230
100.0
341
100.0
Altered bowel habits
Yes
17
15.3
15.3
44
19.1
19.1
61
17.9
17.9
No
94
84.7
100.0
186
80.9
100.0
280
82.1
100.0
p = 0.45 Weight loss
All Yes
111 12
100.0 10.8
10.8
230 23
100.0 10.0
10.0
341 35
100.0 10.3
10.3
No
99
89.2
100.0
207
90.0
100.0
306
89.7
100.0
All
111
100.0
230
100.0
341
100.0
p = 0.85 Bold values are statistically significant
Asymptomatic
Cases are defined as patients with IH
p = 0.0018
Yes
21.6 100.0
46.1 100.0
38.1 100.0
7
6.3
6.3
44
19.1
19.1
51
15.0
15.0
No
104
93.7
100.0
186
80.9
100.0
290
85.0
100.0
All
111
100.0
230
100.0
341
100.0
when the nerve is stretched, which rapidly disappears on release. It takes very little pressure to create discomfort, which resolves when the patient stops straining or sits down [9]. Moderate-severe pain due to hernia is rare, and when present, should suggest the possibility of incarceration or strangulation, which becomes more likely the longer the hernia has been present [10]. In the present study, 30.4 % of the patients with hernia presented urological symptoms, and this figure rose to 33.3 % in cases of RIH. Inguinal hernia is known to be
associated with urological symptoms, and several factors have been described as being involved [8]. On the one hand, the target organ of all the harmful stimuli known in the hernia is the collagen matrix, which is also related to the ageing process in the bladder and other organs. Another possible explanation for this association is that patients with obstructive voiding dysfunction may need to make an effort to urinate, and over time this effort can have a direct impact on the abdominal wall, thus contributing to the development of inguinal hernia. A third
123
Hernia Table 4 Symptoms: status ratio (case/control)
Item
Groin pain
Case (n)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
54
60.7
60.7
16
7.0
7.0
70
21.9
21.9
35
39.3
100.0
214
93.0
100.0
249
78.1
100.0
p < 0.0001
All
89
100.0
230
100.0
319
100.0
Genital pain
Yes
29
32.6
32.6
16
7.0
7.0
45
14.1
14.1
No
60
67.4
100.0
214
93.0
100.0
274
85.9
100.0
p < 0.0001
All
89
100.0
230
100.0
319
100.0
Back pain
Yes No
29 60
32.6 67.4
106 124
46.1 53.9
135 184
42.3 57.7
p = 0.03
All
89
100.0
230
100.0
319
100.0
Cramping in lower limbs
Yes
20
22.5
22.5
39
17.0
17.0
59
18.5
18.5
No
69
77.5
100.0
191
83.0
100.0
260
81.5
100.0
32.6 100.0
46.1 100.0
42.3 100.0
p = 0.26
All
89
100.0
230
100.0
319
100.0
Urinary symptoms
Yes
24
27.0
27.0
44
19.1
19.1
68
21.3
21.3
No
65
73.0
100.0
186
80.9
100.0
251
78.7
100.0
p = 0.13
All
89
100.0
230
100.0
319
100.0
Pain in diaphragmatic area
Yes
17
19.1
19.1
85
37.0
37.0
102
32.0
32.0
No
72
80.9
100.0
145
63.0
100.0
217
68.0
100.0
p = 0.0021
All
89
100.0
230
100.0
319
100.0
Abdominal pain
Yes
33
37.1
37.1
35
15.2
15.2
68
21.3
21.3
No
56
62.9
100.0
195
84.8
100.0
251
78.7
100.0
p < 0.0001
All
89
100.0
230
100.0
319
100.0
Increased peristalsis
Yes
48
53.9
53.9
37
16.1
16.1
85
26.6
26.6
No
41
46.1
100.0
193
83.9
100.0
234
73.3
100.0
p < 0.0001
All
89
100.0
230
100.0
319
100.0
Tenesmus
Yes
23
25.8
25.8
27
11.7
11.7
50
15.7
15.7
No
66
74.2
100.0
203
88.3
100.0
269
84.3
100.0
230
100.0
319
100.0
44
19.1
19.1
59
18.5
18.5 100.0
p = 0.0032
All
89
100.0
Altered bowel habits
Yes
15
16.9
16.9
No
74
83.2
100.0
186
80.9
100.0
260
81.5
p = 0.75 Weight loss
All Yes
89 14
100.0 15.7
15.7
230 23
100.0 10.0
10.0
319 37
100.0 11.6
11.6
No
75
84.3
100.0
207
90.0
100.0
282
88.4
100.0
All
89
100.0
230
100.0
319
100.0
Asymptomatic p = 0.02
Yes
7
7.9
7.9
44
19.1
19.1
51
16.0
16.0
No
82
92.1
100.0
186
80.9
100.0
268
84.0
100.0
All
89
100.0
230
100.0
319
100.0
explanation is based on the fact that inguinal hernia and benign prostatic hypertrophy are part of the ageing process, which provokes functional and anatomical changes. Furthermore, up to 4 % of inguinal hernias may contain part of the bladder (ranging from a small proportion to over half of this organ), which may also provoke urological symptoms [11]. Whether these changes, as a whole, have a cause-effect relationship or are independent factors that are only related to the ageing process has yet to be defined [4].
123
Case (%)
No
p = 0.17
Bold values are statistically significant
Levels
However, except for these symptoms related to local mechanical pressure and urological symptoms, we have not found any previous studies that have considered in greater detail the symptoms presented by patients at other levels, as being related directly or indirectly with inguinal hernia. In this study, we observed more gastrointestinal symptoms in the cases than in the control population, possibly as a result of compression of structures in the digestive tract. For the same reason, hernia patients more commonly present with chronic abdominal pain. One detail that should
Hernia Table 5 Symptoms: status ratio (case/control). Cases are defined as patients with BIH
Item
Groin pain
Case (n)
Case (%)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
21
70.0
70.0
16
7.0
7.0
37
14.2
14.2
No
9
30.0
100.0
214
93.0
100.0
223
85.8
100.0
p < 0.0001
All
30
100.0
230
100.0
260
100.0
Genital pain
Yes
12
40.0
40.0
16
7.0
7.0
28
10.8
10.8
No
18
60.0
100.0
214
93.0
100.0
232
89.2
100.0
p < 0.0001
All
30
100.0
230
100.0
260
100.0
Back pain
Yes No
5 25
16.7 83.3
106 124
46.1 53.9
111 149
42.7 57.3
p = 0.0027
All
30
100.0
230
100.0
260
100.0
Cramping in lower limbs
Yes
8
26.7
26.7
39
17.0
17.0
47
18.1
18.1
No
22
73.3
100.0
191
83.0
100.0
213
81.9
100.0
16.7 100.0
46.1 100.0
42.7 100.0
p = 0.21
All
30
100.0
230
100.0
260
100.0
Urinary symptoms
Yes
9
30.0
30.0
44
19.1
19.1
53
20.4
20.4
No
21
70.0
100.0
186
80.9
100.0
207
79.6
100.0
p = 0.23
All
30
100.0
230
100.0
260
100.0
Pain in diaphragmatic area
Yes
3
10.0
10.0
85
37.0
37.0
88
33.9
33.9
No
27
90.0
100.0
145
63.0
100.0
172
66.2
100.0
p = 0.0034
All
30
100.0
230
100.0
260
100.0
Abdominal pain
Yes
8
26.7
26.7
35
15.2
15.2
43
16.5
16.5
No
22
73.3
100.0
195
84.8
100.0
217
83.5
100.0
p = 0.12
All
30
100.0
230
100.0
260
100.0
Increased peristalsis
Yes
17
56.7
56.7
37
16.1
16.1
54
20.8
20.8
No
13
43.3
100.0
193
83.9
100.0
206
79.2
100.0
p < 0.0001
All
30
100.0
230
100.0
260
100.0
Tenesmus
Yes
12
40.0
40.0
27
11.7
11.7
39
15.0
15.0
No
18
60.0
100.0
203
88.3
100.0
221
85.0
100.0
230
100.0
260
100.0
44
19.1
19.1
52
20.0
20.0 100.0
p = 0.00031
All
30
100.0
Altered bowel habits
Yes
8
26.7
26.7
No
22
73.3
100.0
186
80.9
100.0
208
80.0
p = 0.34 Weight loss
All Yes
30 3
100.0 10.0
10.0
230 23
100.0 10.0
10.0
260 26
100.0 10.0
10.0
No
27
90.0
100.0
207
90.0
100.0
234
90.0
100.0
All
30
100.0
230
100.0
260
100.0
p = 1.00 Asymptomatic Bold values are statistically significant
Levels
p = 0.31
Yes
3
10.0
10.0
44
19.1
19.1
47
18.1
18.1
No
27
90.0
100.0
186
80.9
100.0
213
81.9
100.0
All
30
100.0
230
100.0
260
100.0
be taken into account (although in this respect, the differences in this study were not statistically significant) is that gastrointestinal symptoms and abdominal pain are both more commonly present in LIH than in RIH, probably because the sigma is a structure that passes easily through the left hernial orifice. Another point that arose in our study is that, curiously, there was a lower incidence of back pain and diaphragm pain among the hernia patients than in the control group.
This finding may be related to the existence of a gating mechanism on the medullary dorsal horn [12]. When a painful stimulus on the skin occurs, two types of fibres are activated: on the one hand, fine fibres, which are unmyelinated or poorly myelinated, which produce the painful stimulus; and on the other hand, thick, myelinated fibres, which produce proprioceptive stimuli, carried by afferent pathways to the medullary dorsal horn, where they exert an inhibitory modulation of the pain [13].
123
123
1.7588 1.2150 1.4618 2.7040 1.2999 1.8748 2.0496 0.9898 1.4243 7.2095 3.7778 Tenesmus
1.9796
0.6327
1.7663 2.4030 1.2387 1.7087
0.3373 0.4620
1.4792 2.0263 3.0452 4.5048
0.8063 0.3129
1.5537 2.3059 2.1752 3.2230
0.5023 0.4995
2.1178 3.1783 1.1063 1.8018
0.1578 0.2807
1.5307 2.3931 3.8466 9.6232
0.6961 0.0678
Abdominal pain Increased bowel movements
0.8755 2.5861
0.2172
1.8351 4.9886
Phrenic pain
1.4701
1.5971 1.1040
0.9758 1.1977
1.3279 2.0007
1.9241 0.8479
0.9284 1.3629
1.2773 1.7904
2.1791 1.1821
0.8842 1.2582
1.6049 3.4396
3.4714 0.7823
Urinary symptoms
0.8146
1.6480
1.6739
‘Twinging’ leg
0.7648 0.4843 0.6086 0.9668 0.4489 0.6588 0.6650 0.3015 0.4477 0.6792 0.2685 Back pain
0.1061
2.2730
4.1691 2.8078
1.6731 1.9501
3.4214 7.6533
4.0190 2.1550
3.9355 5.4882
2.9430 3.3100
8.6435 4.4628
1.9204 2.5212
6.2108 28.2933
10.2301 5.5238 Genital pain
6.9900 14.0631 Inguinal pain
2.9826
Lower.CI PR Lower.CI PR Lower.CI PR PR Item
Lower.CI
Upper.CI
Right inguinal hernia Bilateral inguinal hernia
Table 6 Prevalence ratio for the case groups (BIH, RIH, LIH, IH) vs controls
Upper.CI
Left inguinal hernia
Upper.CI
Inguinal hernia
Upper.CI
Hernia
This theory is the basis for the transcutaneous electrical nerve stimulation applied in pain management. In the present case, therefore, the chronic activation of these same afferent pathways in patients with inguinal hernia would exert inhibitory modulation at the level of the spinal dorsal horn, which would explain the lower frequency or intensity of pain [14]. Despite the existence of all the above-mentioned symptoms, some studies have shown that among a significant proportion of patients with symptoms suggestive of inguinal hernia, clinical examination fails to reveal any such hernia [2]. In these cases, imaging tests must be used for diagnosis. In our case group, additional tests were requested for 11.68 % of the patients, with inguinal ultrasound being the most requested (5.19 %). This latter finding is logical, because this test has a sensitivity of 86 % and a specificity of 77 % with respect to hidden inguinal hernias [3]. Hair et al. [15] showed that up to a third of patients presenting with inguinal hernia are asymptomatic at presentation, and that of those suffering pain, this has little effect on their leisure or work activities. However, in our own study only 7.4 % of patients reported being asymptomatic. This difference might have arisen because we took into account a greater number of symptoms, not just locally but also at other levels. Thus, we found a number of physical symptoms and pain-related symptoms occurring at a frequency higher than that observed in the control group. This coincides with other studies [16, 17] in which the SF-36 [18] questionnaire has been used to assess the impact of inguinal hernia on quality of life, and which have concluded that physical functioning, bodily pain and physical role were the domains most affected among patients before hernia repair. In the present study, however, we examine, in particular, the physical functions that are affected (urinary symptoms, increased peristalsis and tenesmus) and the areas most affected by pain (genital, inguinal and abdominal). In view of the above considerations, we believe that the symptoms of patients with inguinal hernia are determined by the constriction of the contents of the hernia within the neck of the sac, and so depending on the content, the symptoms may range from urinary symptoms (entrapment of the bladder neck) to gastrointestinal symptoms (entrapment of the small or large intestine) or the pain symptoms described above (nerve compression). Accordingly, we consider it important to be aware of the symptoms that may develop as a consequence of inguinal hernia, to be able to convey more accurate information to patients when scheduling surgery for inguinal hernia, especially in terms of expectations of symptoms that could be alleviated by the intervention.
Hernia Table 7 Symptoms: status ratio (RIH/LIH)
Item
Groin pain
Levels
Case (n)
Case (%)
Case (R %)
Control (n)
Control (%)
Control (R %)
All (n)
All (%)
All (R %)
Yes
78
70.3
70.3
54
60.7
60.7
132
66.0
66.0
No
33
29.7
100.0
35
39.3
100.0
68
34.0
100.0
p = 0.18
All
111
100.0
89
100.0
200
100.0
Genital pain
Yes
33
29.7
29.7
29
32.6
32.6
62
31.0
31.0
No
78
70.3
100.0
60
67.4
100.0
138
69.0
100.0
p = 0.76
All
111
100.0
89
100.0
200
100.0
Back pain
Yes No
24 87
21.6 78.4
29 60
32.6 67.4
53 147
26.5 73.5
p = 0.11
All
111
100.0
89
100.0
200
100.0
Cramping in lower limbs
Yes
25
22.5
22.5
20
22.5
22.5
45
22.5
22.5
No
86
77.5
100.0
69
77.5
100.0
155
77.5
100.0
p = 1.00
All
111
100.0
89
100.0
200
100.0
Urinary symptoms
Yes
37
33.3
33.3
24
27.0
27.0
61
30.5
30.5
No
74
66.7
100.0
65
73.0
100.0
139
69.5
100.0
p = 0.36
All
111
100.0
89
100.0
200
100.0
Pain in diaphragmatic area
Yes
11
9.9
9.9
17
19.1
19.1
28
14.0
14.0
No
100
90.1
100.0
72
80.9
100.0
172
86.0
100.0
p = 0.07
All
111
100.0
89
100.0
200
100.0
Abdominal pain
Yes
29
26.1
26.1
33
37.1
37.1
62
31.0
31.0
No
82
73.9
100.0
56
62.9
100.0
138
69.0
100.0
p = 0.12
All
111
100.0
89
100.0
200
100.0
Increased peristalsis
Yes
50
45.0
45.0
48
53.9
53.9
98
49.0
49.0
No
61
55.0
100.0
100.0
100.0
p = 0.26
All
111
100.0
Tenesmus
Yes
21
18.9
No
90
81.1
p = 0.30
All
111
100.0
Altered bowel habits
Yes
17
15.3
15.3
No
94
84.7
100.0
p = 0.85 Weight loss
All Yes
111 12
100.0 10.8
No
99
89.2
All
111
100.0
p = 0.40 Asymptomatic p = 0.78
Yes
21.6 100.0
32.6 100.0
41
46.1
89
100.0
18.9
23
25.8
100.0
66
74.2
89
100.0
15
16.9
16.9
74
83.2
100.0
10.8
89 14
100.0 15.7
100.0
75
84.3
89
100.0
26.5 100.0
102
51.0
200
100.0
25.8
44
22.0
22.0
100.0
156
78.0
100.0
200
100.0
32
16.0
16.0
168
84.0
100.0
15.7
200 26
100.0 13.0
13.0
100.0
174
87.0
100.0
200
100.0
7
6.3
6.3
7
7.9
7.9
14
7.0
7.0
No
104
93.7
100.0
82
92.1
100.0
186
93.0
100.0
All
111
100.0
89
100.0
200
100.0
Acknowledgments We are grateful to Rita Perez (FIMABIS) for support on the statistical analysis. Conflict of interest FJPL declares no conflict of interest. ARM declares no conflict of interest. HOM declares no conflict of interest. Author contribution FJ. Pe´rez Lara: Conception and design, acquisition of data, analysis and interpretation of data, drafting the article, final approval of the version to be published. A. del Rey Moreno: Acquisition of data, revising the article critically for important intellectual content, final approval of the version to be published. H. Oliva Mun˜oz: Acquisition of data, revising the article
critically for important intellectual content, final approval of the version to be published.
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